Your Foot Care Guide from Heel to Toe

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Scrunching your toes into high heels can put certainly put unhealthy pressure on your feet. But poor circulation caused by many chronic conditions can cause even more dangerous symptoms.

Join us as our expert guests talk about the importance of regular foot care to maintain long-term foot health. You’ll hear about which types of shoes to avoid based on your particular foot shape; why poor blood circulation and excess weight can cause serious damage to your tootsies; and how simple techniques can help your feet stay strong and pain-free in the future. Plus, you’ll learn how to safely control and lessen foot pain you may already have from arthritis or other conditions.

As always, our expert guests answer questions from the audience.

Announcer:
The opinions expressed on this webcast are solely the views of our guests. They are not necessarily the views of HealthTalk, our sponsors or any outside organization. And, as always, please consult your own physician for the medical advice most appropriate for you.

Judy Foreman:
Hello and welcome to Health Now. I’m your host, Judy Foreman. The average person walks the equivalent of three times around the earth in a lifetime. That puts an enormous amount of wear and tear on the feet. Tonight we will talk about the importance of maintaining good foot health. You will learn about common foot problems and what you can do to avoid them.

I am very pleased to welcome Dr. Ross Taubman, president of the American Podiatric Medical Association. He is a practicing podiatrist in Clarksville, Maryland, and he’s on the surgical staff of the Howard County General Hospital and the Center for Ambulatory Surgery. Dr. Ross Taubman, thank you so much for joining us tonight.

Dr. Ross Taubman:
Judy, thank you for having me. It’s a pleasure to be here.

Judy:
Great. Well, can I call you Ross?

Dr. Taubman:
Please.

Judy:
Terrific. Well, just to get us off on the right foot, as it were, remind us what the difference is between a podiatrist and an M.D.

Dr. Taubman:
Judy, a podiatrist is a doctor of podiatric medicine. Podiatrists are physicians and surgeons who are qualified by our education and training to diagnose and treat conditions affecting the lower extremities, foot, the ankle and the lower leg. Podiatrists are the only doctors that receive specialized medical training and board certification solely in the care of the foot and ankle. The preparatory education for podiatrists includes undergraduate school for four years, podiatric medical school, and then residency training in a hospital system. And podiatrists are licensed in every state, including Puerto Rico as well.

Judy:
So the training seems kind of pretty equivalent to an M.D. but just more focused on feet?

Dr. Taubman:
I think that’s a pretty good analogy. The first two years of podiatric medical school are nearly identical. Podiatrists learn about the whole body, full body systems and then begin their specialization in the third year and then go on to more advanced training. But we are the only providers who specialize solely, all of our training is solely related to the foot and ankle.

Judy:
And I am curious of all the medical specialties out there, what made you decide to choose feet?

Dr. Taubman:
Well, it’s an incredible time to be a podiatrist. I can tell you that. Me personally, my father is a podiatrist, so that’s how I got started in this business. But the American Podiatric Medical Association recently had a study commissioned by the State University of Albany Workforce Center, and one of the findings of that study is that the need for services by podiatrists are going to triple in the next three decades. Primary reasons for those kinds of projections are obesity, diabetes and an aging population. So what I would tell you is it’s an incredible time to be a podiatrist. And if any of the listeners are considering a career, it’s a wonderful choice.

Judy:
So it’s more the economic reality than a pure fascination with the feet?

Dr. Taubman:
Well, I think for me it was a fascination of the feet that I sort of got through osmosis. And I think that for many people one of the great things about being a podiatrist is that when we treat our patients, we almost always can make them feel better at the time of the visit and even for some of the things that we see that are related to chronic disease. So clearly it’s a wonderful specialty of medicine and one that I highly recommend.

Judy:
Well, that’s certainly more than most doctors can say, that they can make people feel better right away.

Dr. Taubman:
I think you are right.

Judy:
Yeah. So how common is foot pain in the U.S.? I have read that your group, the American Podiatric Medical Association, has recently done a survey showing that 53 percent of respondents say they have foot pain that’s so severe that it hampers their daily functioning. Can you tell us a little bit more about why this is and why it’s so common?

Dr. Taubman:
Well, first of all, what people should know is that foot pain is never normal. If you have foot pain, that’s a reason to go see a podiatrist. It just should never occur. The vast majority of us do experience foot pain at some point during our life. You talked earlier about the amount that the average person walks in a lifetime. That’s a lot of stress to put on our bodies, and then you start to couple that with some of the chronic problems that we have like obesity and diabetes, and that really creates tremendous problems for the feet. And lastly, think about the things that we do to our feet that are different from any other body part. What I am talking about is we try and squish them inside shoes, and for many of us it’s like trying to stick a square peg in a round hole. The shoes that we wear are not shaped like our feet, and that’s a prescription for problems down the road. So it’s really just a common problem. Unfortunately, many of us think it’s just a normal part of life, and it’s not.

Judy:
Yeah. I was going to ask you, is foot pain an inevitable part of aging? Or is it really something that you should not just sort of give up and shrug your shoulders about?

Dr. Taubman:
I would never say to anybody that foot pain is inevitable. I think there are things that happen in the aging process, most of us gain weight as time goes on, and that adds problems. Many of us become more sedentary, and that can relate to problems down the road. Some of us, unfortunately, inherit some of our traits. We might have flat feet. We might develop bunions. We might develop hammer toes or other problems. So some of us get them the good, old-fashioned way, which is from our families, but many of the things that we see are preventable with appropriate foot care and appropriate shoe wear, and, again, nobody should have to suffer from foot pain at any time during their life.

Judy:
But really, do we have more foot pain than, say, knee pain or hip pain from all this walking around the earth three times in a lifetime? I mean do the feet have it any worse than the knees or the hips?

Dr. Taubman:
Well, I think that the feet get their fair share of abuse over time. And I think that the other issue, which I pointed out, is we do put our feet inside shoes. And if shoes don’t fit well, that’s another factor that can lead to that. Certainly the other body parts get their fair share of problems and arthritis in the knees and sort of wearing-out problems, and we do get arthritis in the foot as well. So I’m not one to tell you that the feet get more pain necessarily, but clearly most people experience foot pain at some point during their life, so it’s clearly something that people need to be concerned about.

Judy:
So as you said, feet are not supposed to hurt. And if they do hurt at least chronically, you should probably go see a podiatrist. But what are the major foot problems that people have? I would like to sort of go through them one by one so that listeners can kind of identify what’s ailing them and ask you by e-mail or by phone call. First, bunions, I gather that bunions are essentially misaligned big toes and that they run in families, but is that the only cause? Do bad shoes cause them or anything else that we actually do contribute to bunions?

Dr. Taubman:
Well, first of all, bunions are a malposition of the big toe joint that causes a bump at the base of the big toe joint, so it sticks out on the inside of the big toe joint there. About 10 percent of American women suffer from bunions during their lifetime.

Judy:
And what percent of men?

Dr. Taubman:
It’s a smaller percentage of men that develop them but not that much smaller. The rate of bunions in men and women is pretty close to the same, but they are symptomatic in women significantly more often for the obvious reason of shoes and the kinds of shoes women wear compared to men.

The causes of bunions, there are multiple factors. Heredity is one of them. Trauma can be another cause. Biomechanical abnormalities can cause it. Neuromuscular disorders can cause it. Inflammatory arthritis can cause it, just to name a few. And what I would say is that shoes never cause bunions. Shoes make bunions hurt, but they never cause bunions. If you picked up a copy of National Geographic magazine and you looked at tribes people from Africa, you might see bunions on people’s feet that never owned shoes. So a lot of people think that shoes are the reason that people have bunions. For many of us, shoes are the reason that bunions are symptomatic because they apply pressure to that area.

Judy:
I never heard that point made so clearly. That makes a lot of sense. So if we all just wore wide enough shoes, even if we had bunions, we wouldn’t have bunion pain?

Dr. Taubman:
For many of us, that’s the case. Now, if you had arthritis in the big toe joint associated with your bunion, you may still have pain even without shoes because your joint may not bend normally, and normal walking may be painful in that particular instance. But for the vast majority of people that have bunions without arthritis, shoe wear can be the greatest reason why you are comfortable.

Let’s talk about shoes for a second. One of the biggest problems we have, especially for women and especially in shoes that are slip-on shoes, it’s hard to find shoes that are wide enough in the front that stay on the back of your foot. As you get a wider shoe, most of the time that means the heel is going to be wider. If the heel is wider, it’s going to mean your heel slips up and down when you walk, and so many women buy shoes that are too narrow in the front because they are trying to keep it on the back of their shoes. So it’s real, it’s difficult. There are shoes out there that are better for your feet that women can find, but you have to search a little bit to find those.

Judy:
It just strikes me that that’s a pretty dumb problem because if you know that and all the other podiatrists know that and even women who shop for shoes kind of know that, why don’t shoemakers make shoes that are wide in the front and narrow in the back?

Dr. Taubman:
Judy, that’s a question I’ve been asking for a long time trying to figure out why is it that they don’t do that. What I have learned in talking to some of the manufacturers, if you go back a number of years, you used to be able to buy a shoe that was made on a mold called a “last.” They are still made on a mold called a last, but they used to be made on a combination last, which meant that you could ask for a shoe that, say, had a B width in the front and an A width or a AA width in the back. That’s become more costly to manufacture shoes that way, so they tend to make shoes on a single last. And what that normally means is that as they make the front wider, they also make the back wider. So I think there is a lot of room for the manufacturers to help us out here and create shoes that are more like people’s feet. And we could ultimately help a lot of people from suffering from this particular problem.

Judy:
So what do you do if you have bunions, aside from choosing your shoes better or going barefoot I suppose when you can? Do they get corrected by surgery or pain medications, or what do you do?

Dr. Taubman:
Well, let’s talk about the kinds of things you can do if you have bunions. First of all, we talked about shoes, and shoes are really the first place to look. And you want to avoid shoes that are too narrow, as I said. You also want to avoid shoes that have stitching or seams right over that area because that applies extra pressure. You want to find shoes that are not pointy in the front so that they allow the foot, when you bear weight for the foot, to expand a little bit there.

Some of the things that you can do that are conservative measures aside from shoes are things like soaking your feet in warm, lukewarm water. If there is pain, that helps relieve the pain. Some people can take an over-the-counter anti-inflammatory medication like ibuprofen, and that helps. Cold compresses sometimes help if you are having pain.

And then if those things aren’t helping, it’s time to go see the podiatrist, and the podiatrist will talk to you about various aspects of treatment. Number one, again, will be shoes, and some discussions on where to go and how to find shoes that are appropriate. Two, sometimes we utilize an insert inside the shoe called an orthotic. An orthotic is a custom-made support that is designed essentially to block the rolling in motion of the foot, or pronation. What the orthotic does is it helps prevent the bunion or the bump on the inside of the foot from rolling in to the inside of the shoes. So, in some shoes, that may be appropriate. Keep in mind one orthotic is not so easy to use from shoe to shoe if you use multiple different styles.

And then lastly, of course, there is surgery. And what surgery does is it addresses the structural abnormality that is seen and, in many cases, involves actually having to cut the bone and move it back into place. It’s not so simple, in most cases, just to shave down where the bump sticks out because keep in mind it’s a malposition of the big toe joint, and that almost always needs to be re-aligned.

Judy:
That surgery sounds like a pretty big deal. I mean it sounds like it’s not such a trivial procedure, and obviously you’ve got to be off your feet afterwards, right?

Dr. Taubman:
It’s not a trivial procedure. And I tell all of my patients it’s certainly not something that you do on Friday and you are fine on Monday. Now, if it’s handled in the appropriate way, most of the time the healing is uneventful. But it can take several months for most people to get back into all of their shoes comfortably, and it can take almost a year before all the swelling is gone and the full range of motion of the joint comes back. So the decision for surgery is one that patients need to make with consultation from their podiatrist, but also they need to think about their lifestyle, how it will affect them.

Here is one example. Think about if you have surgery on your right foot and you need to be off your foot for several weeks because of the surgery. How are you going to drive a car? It’s pretty hard to drive a car. So many people need help to be able to get them from place to place. Many surgeries you can begin to walk on your foot very shortly within that day or even days of surgery. There are some procedures that are done that you can’t walk on your foot for six to eight weeks afterwards.

Judy:
Do you mean for bunions?

Dr. Taubman:
For bunions. And what determines that is going to be the underlying structure and how significant the deformity is and how big the angulation of the bones are. So there isn’t such a thing as only one bunionectomy procedure. The podiatrist will select the procedure based upon the individual anatomy and individual history and physical examination for that patient. So one size does not fit all when we get to bunion surgery.

Judy:
Wow. It’s pretty sobering to think about that. What about a less severe problem, corns and calluses, are they just dead skin? Is that hereditary too? And can we just kind of file those down and forget it, or do they have any more serious medical import?

Dr. Taubman:
Well, one of the interesting facts is about 25 percent of American women say they have experienced calluses as a result of ill-fitting shoes. Corns on toes, corns are thickening to the skin that are on toes primarily, and they are generally caused by rubbing of the shoes.

Judy:
Are corns and calluses the same thing, or are they different?

Dr. Taubman:
Well, they are both anatomically the same. A callus is typically on the sole of the foot, and a corn is typically on the toe if I could separate those two things.

Judy:
Okay.

Dr. Taubman:
But they are both thickenings of the skin. Now, corns are almost always caused by rubbing of the shoe against the bony part of the toe. If you think about your toes, most of them are pretty skinny. There is not a lot of fat in there. You have skin and you have bone. And when the shoes rub on those areas, you will develop a corn.

And on the bottom of the foot, we call it a callus. Calluses are typically caused by bony pressure. In other words, it could be pressure from the way that you walk, a biomechanical abnormality, or it could be caused by a misposition of the bone where the bone is prominent. So the reasons for calluses are slightly different.

The treatment of corns and calluses vary depending on the causes and the individual circumstances. It’s not a good idea to just start taking a knife or a scissors and start hacking away at the skin. First of all, it’s never going to make it go away.

Judy:
I agree with that.

Dr. Taubman:
That’s the first thing. The second thing is, I don’t know about you, but my feet are the least accessible part of my body for my hands. They are the farthest away, and unfortunately as many of us get older, we have a harder time reaching our feet.

Judy:
They get even farther away.

Dr. Taubman:
Yeah. I keep saying that as I get older, my legs keep getting longer and my arms keep getting shorter because I have a harder time reaching. But what happens is a lot of people try to deal with it themselves. If you understand that corns are caused by rubbing of the shoes, you will also understand why corn medicine, which is acid, will not make them go away. Unless that corn medicine eats the bone inside the toe or eats the shoe, it’s not going to make it go away. So those are not a good idea for people to try to use.

It’s okay to use non-medicated corn pads, and non-medicated callus pads. Those are both perfectly fine to use, and they are safe for most people to use. The medications, the medicated items and using medication is not a safe means. If the callus needs to be shaved down, that needs to be done by a professional.

Judy:
Well, what about going to get a pedicure, I mean, those people aren’t exactly professionals, but lots of people, especially women, do get pedicures, is that a good idea or not?

Dr. Taubman:
Well, I am going to say it depends, and there are issues about most pedicure shops. First of all, none of the pedicurists should be using a sharp instrument to shave down corns and calluses. They should be using a sanding-type implement that’s much safer for somebody that doesn’t have expert training to use.

Judy:
So like no razor blades should be used?

Dr. Taubman:
No razor blades. They should not be using a razor blade. The second problem that we are concerned about in the salons is the sterility of the instruments that they use. If you come to my office and I pull out a scalpel, which I might use to trim your callus because I am trained to do that, I also sterilize that instrument after every single use. In fact, in my practice, we throw away the blade after every patient. So I am using brand-new sterilized blade on every single patient. You think about salons. They use implements they have used on the person before them that they have maybe soaked in a solution. They haven’t necessarily sterilized them thoroughly so that all the germs are killed. So that’s another area of concern.

Now I don’t want to say that all salons are bad, but you need to be careful about the salons you pick and try to find ones that you know are treating the instruments correctly. And again, none of the salons should be using a sharp instrument to remove a corn or a callus. They are just not trained.

Judy:
Well, actually that kind of raises a bigger question. Should you try to get rid of calluses? Because I have actually had doctors tell me that it’s kind of like the history of your gait and the way you walk is written in your calluses, and they can tell things about your posture and how you move your body by the calluses. And obviously they come back once you get rid of them anyway. Do we need calluses to kind of protect the bones or something?

Dr. Taubman:
Well, calluses are the body’s way of trying to protect an area. Clearly on the bottom of the foot you are getting pressure, the bones are perceiving pressure, and it puts extra skin there. For some patients that’s perfectly asymptomatic. It doesn’t cause any problems. For other patients it can be a source of pain, and it’s when it’s a source of pain that it needs to be looked at appropriately by a podiatrist so that they can evaluate what the cause is. And clearly it’s preferable to try and treat the cause. If it’s a biomechanical issue, address it that way. If it’s a structural issue, sometimes it’s addressed from a surgical means to be able to address the structure. So finding out the reason is really important, and that’s generally not something a lay person can figure out for themselves.

Judy:
Yeah. Well, moving on again to a little more serious thing, hammertoes. These look pretty bad because the toes are kind of bent in a funny, claw-like position. Are these, like bunions, partly genetic, or are they also aggravated by bad shoes? And just describe for us what the hammertoes actually look like.

Dr. Taubman:
Okay. A hammertoe is a bony prominence that appears on a toe, and the toe appears to be bent or what we call contracted. So if you think about your toe, your toe is supposed to be straight when it’s sitting on the ground. If your toe sticks up and you can see the knuckle, or there is a mark where the knuckle is, that’s generally what we call a hammertoe. And hammertoes and corns often go together because it’s at that bent part of the toe or the bony prominence where the shoe rubs, because the shoe is not shaped exactly like the toe, and it rubs.

Judy:
So wait. Do the ends of the toes go down towards the ground or up towards the top of the shoe?

Dr. Taubman:
The very end of the toe tends to either stay flat or point down towards the ground, sort of so the toenail is facing down.

Judy:
I see.

Dr. Taubman:
The primary place people see the bump is at the first knuckle of the toe, the one that’s closest to the meat of the foot, and that’s where they see the bump. The causes of hammertoes primarily are genetic. They are hereditary. Ill-fitting shoes can cause the toes to buckle, so that’s an area where you do have to be careful. Muscle imbalance can cause it, so sometimes for biomechanical reasons or neuromuscular reasons we see contractions of the toe. And then arthritis can also cause the toe to contract and form a hammertoe as well. So the causes are varied.

Interestingly, one of the studies that the American Podiatric Medical Association survey recently did is that women suffer from them twice as much as men. I think the primary reason is the kinds of shoes women wear.

Judy:
Yeah. That seems to be a common theme in what you are saying. You have mentioned arthritis a couple of times, and I’m sure we will get some questions about that from listeners too. But we have all heard of knee replacements and hip replacements for osteoarthritis. What about toe joints, I mean are there replacement surgeries for arthritic toes and big toes and feet?

Dr. Taubman:
Sure. There actually are. There are joint replacements in the big toe joints that have been done for about 50 years.

Judy:
Wow.

Dr. Taubman:
And they are not, I won’t say it’s the most common thing that’s done because it’s not. But they are commonly done to replace the big toe joint, and they come in different configurations and different materials, much the same as a knee replacement or hip replacement. And the technology has evolved over time from plastic joints to now using metals more commonly. There are still some plastic joints that are around. And it’s also expanded to some of the other smaller toes where there are now prostheses or implants that are used for those toes on certain occasions. And the other area that’s sort of newer in the world of implants is in the ankle joint where there are some greater number of ankle joint replacements that are being done. It hasn’t been done nearly as long as the big toe joints have.

Judy:
It’s funny that you never hear about this though. I have never heard anybody ever say they have had a total ankle replacement or a total toe replacement. Is it pretty common, or still pretty rare?

Dr. Taubman:
Well, it’s not that common. It’s not one of those procedures that is done that frequently, and it’s done for arthritis of the ankle. The pain has to be very severe. In the past, the primary treatment when it became a surgical problem was to fuse the ankle joint, and that’s still probably the mainstay in medicine. And a vast majority of patients that have ankle joint arthritis that have surgery still have a fusion where the bones in the ankle joint are tied together.

Judy:
Does that get rid of the pain?

Dr. Taubman:
Well, the reason people have pain in arthritis is because the cartilage that’s at the joint starts to wear out. And when you try to bend a joint, it bends with friction and it grates, and that creates pain. So if you fuse a joint and make it so it doesn’t bend, you can eliminate the pain. Now, that’s not without its own set of issues that you have to think about. If you fuse a joint, first of all your body was made so that you could bend that joint. And if we surgically make it so that joint doesn’t bend, that movement has to go somewhere, and it typically goes to the next higher joint or the next lower joint. It’s got to go somewhere. Those forces have to travel somewhere through the foot or up into the leg. So although we do fusions, and we do them with much thought about what the consequences will be, sometimes you don’t have a choice. You have a patient who is not walking at all because they have severe pain. We want to make it so that they can walk, but we know that we have to pay attention to some of the consequences down the road.

Judy:
Yeah. That makes total sense. What about just regular old heel pain and heel spurs, what are those things, and what can people do about them?

Dr. Taubman:
Well, heel pain and heel spurs are one of the most common things I see in my practice. About 20 percent of American men and women will have heel pain at some point during their life, according to a recent survey the APMA did. The most common form of heel pain is what’s called plantar fasciitis, or heel spur syndrome. And the classic description of that is that, “When I get out of bed and I stand up, my heel hurts. When I walk for 10 or 15 steps, the pain gets better. If I sit for a period of time, I get pain again.” And it keeps repeating that pattern. Eventually as the problem gets worse, the symptoms become more constant, meaning that the patients will have pain from the time they stand up to the time they get off their feet. So that’s sort of a progression of the problem.

I think one of the interesting things I’ve noticed in my practice is most people when they have heel pain associated with plantar fasciitis say that they have had the pain for six months, and they thought that they bruised their heel and it will get better. For some reason, patients cannot come in and say, “I know why I have the pain. I had something happen.” In most cases, they can’t relate an event as the starting point. They just know that they have pain.

And if you think about the foot, every step you take causes the ligament which is called the plantar fascia, which attaches from the heel and then runs the length of the foot to the ball of the foot, that ligament is stretched every time you stand up. The reason we get pain with initiating walking is you have been off your foot, your foot relaxes, that ligament contracts. And when you first stand, if that’s been injured or hurt, as you stand up, it’s going to pull on that injured area. So that’s why the patients will report pain when they first initiate movement.

It’s really important, one of the very first things that you need to try and do if you have that is to wear shoes that have good support because every step you take without support causes more strain on that ligament and sort of fosters the problem. So one of the things I tell my patients is don’t walk in your house barefooted, without shoes, in slippers that are flat and just socks if you have heel pain. It’s going to make it worse. Find a shoe that you can wear in the house that has better arch support. If your pain is persisting for more than a couple of weeks, you need to go in and see a podiatrist and see what’s up, make sure that the diagnosis is plantar fasciitis. There are other causes of heel pain besides plantar fasciitis, but you want to make sure that’s the cause, and then treatment can be prescribed by the podiatrist.

Judy:
It sound like the reason it hurts in the early morning is because the ligament is contracted. Couldn’t you just lie in bed and sort of flex your foot and stretch a little bit before you tried walking on it?

Dr. Taubman:
Very perceptive, Judy.

Judy:
Yay.

Dr. Taubman:
One of the things that happens is if you can stretch before you get out of bed, you can minimize the pulling of that ligament, and it will feel better. There are also these devices called night splints that people can sleep in that hold the foot and prevent that ligament, the plantar fascia, from contracting. So that is another option that people can use as well or to try. Again, if it’s not working or you are not getting better, it’s time to go see the doctor.

Judy:
And what about toenail fungus? It’s kind of a little bit of a gross topic, and it sounds trivial, but I gather it’s not really trivial. How do you get toenail fungus, and what can you do about it?

Dr. Taubman:
Well, toenail fungus affects almost 20 percent of the population at some point. And there could be many reasons why you get it. It can be the result of a traumatic injury to a toenail. It can be that for heredity reasons you inherit a susceptibility to the fungus. The funguses that cause toenail fungus, they are at your house, they are at my house, so they are everywhere. So you don’t necessarily need to go somewhere and get it. It can come and get you.

What happens is that the fungus invades the tissue underneath the nail, causes the nail to get thicker. It typically looks yellowish in coloration. It looks crusty. There is almost like chalk underneath the nail. And the nail could be thick and painful. It could be one of the causes of ingrown toenails. So if you have thick toenails like that, it’s not a trivial problem. If it hurts, it’s bothering you, you need to go see somebody about it.

Judy:
Well, is it actually an infection?

Dr. Taubman:
It’s an infection of the nail. That’s right. The fungus is an organism, and it infects the nail and makes it thick, and oftentimes it requires medication to be able to fix it.

Judy:
And what do you take for this, Lamisil (terbinafine) or one of these other anti-fungals?

Dr. Taubman:
Well, sometimes people will prescribe topical medicines. Topical medicines are very safe. There are very little side effects. The problem is they are not as effective as the pill medicines, like Lamisil. Lamisil is the most common drug. It has a generic name called terbinafine, which is now a generic drug. So there is not just one drug. There are many companies that now make generics. They work. The success rate of using it is about 80 percent, but you need to be evaluated and a decision needs to be made about putting you on it.

It’s not a medicine that is solely without side effects. The biggest issue associated with Lamisil is a very small percentage of people can develop problems in the liver, liver toxicity associated with it. And in very rare instances, and I am talking about a very small number of people, maybe one in 100,000 can develop liver damage from taking it. So it’s something that you don’t just want to take on your own without thinking about it. The other medicines that you take play a factor in it. The general health of the patient is really important too. If you are somebody who has had hepatitis or some other liver problem, you are not a very good candidate to take Lamisil.

Judy:
Yes. It would seem like it would be quite a shame to get a messed up liver just because of a toenail fungus.

Dr. Taubman:
Yeah, I think you are right. And I think if you are going to take that medication and your sole reason to take is a cosmetic reason, you really need to talk with your doctor about whether that’s appropriate or not.

Judy:
Yeah. And what about neuromas? I have actually had one myself, and I know that mine was called a Morton’s neuroma. And it can really hurt. It’s kind of a benign tumor that in a lot of people grows between their second and third toes of their foot. Why does that happen, and what can be done about it? I know I had surgery, but I don’t know if there are other options as well.

Dr. Taubman:
Well, we are not really a hundred percent sure why people develop neuromas. And as you mentioned, a neuroma is a benign growth of nerve tissue. The most common areas of the foot are between the third and fourth toes, and the second and third toes are the second most common. We count the toes from the big toe as number one to the little toe as number five.

Judy:
I was going to say which is number one.

Dr. Taubman:
Number one is the big toe. So if you are counting, the second and third toes, that’s the toe next to the big toe and the middle toe, and keep counting along. But we are postulating that the causes could be improper fitting shoes, high-heeled shoes have been implicated, trauma, heredity, there are all kinds of reasons. We are not exactly sure.

The primary symptoms of a neuroma are burning, tingling, a numb feeling of the toe that starts in the ball of the foot and sort of radiates out into the toes. The anatomy is such that there is a nerve that runs between the long bones of the foot where the ball of the foot is. Those are called the metatarsals. And then when it gets to the toes, that nerve branches and goes to the contiguous toes. So for the second space, the one between second and third toe, it branches into the second and third toes. So people often feel a burning or searing pain that radiates out into the second and third toes and can be very debilitating. One of the unusual things that patients sometimes say to us is that it feels like my sock is wadded up on the ball of my foot.

Judy:
Yeah, it does.

Dr. Taubman:
And so you are justifying what I said. But a lot of people take their shoe off, and they keep looking to see if the sock is on it, and that’s because the nerve is irritated and the feeling is not normal. And when it’s not normal, patients will describe that kind of sensation.

Now, you had surgery where your doctor went in and they cut that section of nerve out to eliminate the nerve pain. Other common treatments prior to surgery, and you may have had some of these, sometimes a specialized pad is used to try and separate the bones. It’s typically called a metatarsal pad or a neuroma pad that’s designed to try and spread the bones apart. That’s sometimes used in conjunction with an orthotic, the shoe insert I talked about before. Sometimes it’s injected with cortisone as a way to decrease the inflammation or the swelling around the nerve.

And then when we get to treatment, surgical treatments, you had the traditional treatment which is to cut the section of nerve out. Sometimes there are doctors that inject that area with a high concentration of alcohol. Alcohol is known to cause the nerve to sort of shrivel up, and that sometimes is a way that people treat it. It needs to be done by somebody who is experienced because alcohol also potentially could cause not just the nerve, but it can cause the artery and the veins that are there to shrivel up, and we certainly don’t want to do that. So it needs to be done by somebody who is well-versed in doing that. But surgery like you had is the mainstay or probably the most common way that a neuroma is treated once we have failed in the cortisone injections and failed the other kinds of things we talked about.

Judy:
Yeah. I can speak from personal experience just as with all these other foot surgeries, you are off your feet for 10 days or so, which means you are hobbling around with crutches and with a backpack on and all that stuff. It’s not trivial when anything happens with your feet.

Dr. Taubman:
No, it’s not. And I don’t ever want to downplay the first things people should do like trying to find shoes that are wider because, in some cases, that may solve the problem if shoes are what’s causing the compression against the nerve. But again, if it’s persisting and you are having foot pain, go see your podiatrist. They will be able to help you.

Judy:
We have a couple of e-mail questions that have come in. One is from Wallace in Florida. He writes, “What can be done to lessen the pain and symptoms associated with flat feet in older adults? This condition makes walking painful, and I need to walk for health reasons.” Dr. Taubman?

Dr. Taubman:
Well, flat feet is a common problem.

Judy:
Okay.

Dr. Taubman:
The main reason people have flat feet is because they inherit that through their genes. You can also develop flat feet from trauma and other neuromuscular problems as well. But the first thing that anybody with flat feet needs to do is they need to go and get an evaluation, make sure that there is not a more major problem that’s causing the flat feet such as a neuromuscular problem, but as a patient getting shoes that fit your feet that are cushioned and have the right amount of support is the very first thing that you should be doing.

One of the things I haven’t mentioned is there are some shoes that have gone through a very significant vetting process through the American Podiatric Medical Association. If you go to the Web site at the APMA, which I will give you in just a second, those shoes have garnered a seal of acceptance. They have actually been evaluated by a team of podiatrists who are experts in footwear, and that’s one of the things that listeners can do in trying in trying to find a shoe that’s really of better quality, better support for them. But shoes are the very first things. That Web site is www.apma.org, and you are looking for the seal of acceptance. It’s a really important tool that the listeners need to think about when they are looking for not only shoes but other products as well.

Judy:
I haven’t been to that site yet or that part of it. Do you actually do brand names?

Dr. Taubman:
There are actually brand names. What happens is that companies apply for the seal of acceptance. They submit their products, and those products go through a significant, strenuous evaluation process based on a number of criteria that the experts have come up with. So it’s done for shoes. It’s done for other products as well, not just shoes. Some insoles are there. Different kinds of products have been given that seal of acceptance, and those are things that the listeners could look for. And if you are looking at products, you often will see that on the box of the product. It will say seal of acceptance, American Podiatric Medical Association. That tells you that it’s been a through a process, and the product you are getting is quality.

Judy:
Well, that is a perfect segue to our next e-mail question, which comes from Swampscott, Massachusetts. And a listener there writes, “Are there any good, off-the-shelf shoe inserts? I can’t afford orthotics.”

Again, not only your site, but off the top of your head, can you rattle off any orthotics that are not too expensive and you can just go to the store and buy? Do you have that advice?

Dr. Taubman:
Yes. There are a number of really good products. You can go to the Web site and look for that. One in particular that makes a very decent product is a company called Spenco. They make multiple kinds of supports, and many of their products have gotten the seal of acceptance from the APMA, and they are not nearly as expensive as a custom orthotic. And they range in price from about $20 to about $35 or $40, so much less expensive. But keep in mind that a custom orthotic is very different in design and function and certainly in price than an over-the-counter support. But in many cases, looking for those kinds of products with the seal of acceptance can point you in the right direction for a product that’s quality and not that expensive.

Judy:
Well, I have to ask you the obvious potential conflict of interest question. I assume that neither you nor the American Podiatric Medical Association has any financial ties to any of the products that you recommend?

Dr. Taubman:
I have no financial ties to any product whatsoever.

Judy:
And what about the association?

Dr. Taubman:
The association does get corporate sponsorship for its educational programs like every other medical organization does. So there are companies who do contribute money to the APMA that are part of our educational process. It’s how we put on our seminars, and they give unrestricted grants that we then use. There is always a disclosure by the companies and also a disclosure by the presenter if they have a conflict. For instance, if I was somebody who was on the board of Spenco, I certainly would need to tell you that I had a conflict because that’s something you should know. So that information is always given by the presenters related to that. But we do have corporations who do sponsor our educational activities.

Judy:
But that is a separate process from the seal of acceptance?

Dr. Taubman:
Absolutely. One has nothing to do with the other. You do not by making a contribution guarantee in any way, shape or form. The people that make those decisions do them irrespective of whatever partnerships there are between APMA and those companies, and so it is a completely aboveboard process. One has nothing to do with the other.

Judy:
Great. I figured that was the case, but I just wanted to make it clear and get it on the record.

We have another question from a listener in Sammamish, Washington. She writes, “My 11-year-old was just diagnosed with tendonitis in both feet. Are there any treatment recommendations you can make?”

Dr. Taubman:
Well, tendonitis is an inflammation of the tendons. It’s not specific as to where that is. But the common treatments for tendonitis are rest, in other words stop doing what’s causing the tendonitis in the first place. Ice is also very helpful. Ice decreases inflammation. Sometimes wrapping it with a wrap providing compression is helpful. If there is swelling, you want to elevate the body part. And then immobilization is sometimes used, and in some cases if it’s severe enough, I will even put my patients into a cast if I need to really get things to quiet down. So there is really a whole host of things, but the first thing is to eliminate what’s causing it, and I would try ice. Some people do take anti-inflammatory medications to try and make the pain better and to decrease inflammation. That sometimes is prescribed as well.

Judy:
Okay. We have actually skirted around in some ways, the most serious of all the foot problems, and that is the myriad of problems caused by diabetes. And diabetes as everybody knows now affects millions of Americans, and it’s driven in substantial part by the obesity epidemic. Why does diabetes cause pain and infection and other problems in the feet?

Dr. Taubman:
Well, first of all, diabetes is at epidemic proportions in the United States. The estimates are about 24 million Americans have diabetes. The really unfortunate thing, Judy, is about 6 million of those don’t even know they have diabetes in the first place, so that’s really a terrible problem for this country.

Specifically with regards to feet, diabetes causes two separate problems that work together to create problems. The first is increasing blood sugar, which is what diabetes is where your blood sugar increases in the bloodstream, can cause damage to the nerves in the feet and the legs. What this can affect is the ability to feel things normally. If you couple that with the second problem, which is that diabetes can affect blood flow, what happens now is you have a situation where you don’t feel things very well, and you don’t heal very well because you don’t have enough blood. That leads to sores on the feet, which we call diabetic ulcers, which are what lead to the amputations that can happen associated with diabetes. According to the CDC, it has caused more than 90,000 amputations annually.

Judy:
The CDC, in case people don’t know, is the Centers for Disease Control. It’s part of the federal government.

Dr. Taubman:
That’s correct. And they are centered in Atlanta, and they provide a myriad of statistics on diseases in the United States. And according to the CDC, about 90,000 amputations get done annually in the United States associated with diabetes. That’s really something that this country needs to work on very hard because we are a country that has the greatest access to medical care, the most advanced techniques, and yet we keep seeing that amputation rate rise, so that tells us we have a serious problem.

The good news is that 45 to 85 percent of amputations can be prevented with appropriate foot care provided by a podiatrist. So most of the patients who develop diabetes don’t lead to an amputation, and most of it is preventable if they would just get care.

Judy:
Well, you have actually set up a perfect segue once again for another e-mail question. This one is from Angela in Hillsborough, New Hampshire, and she writes, “Can you recommend a routine for diabetic foot care?” What should you do if you have diabetes and don’t want your feet amputated?

Dr. Taubman:
Well, it sounds very obvious. The very first thing that every patient with diabetes should do is to look at their feet. I know that sounds silly, but the vast majority of us only pay attention to our feet when we think there is a problem. And if you are not feeling things the way that you should, you have diabetes, you have neuropathy, which is the nerve damage associated with that. You don’t feel things, that mechanism of pain is going to be altered, and you are not going to feel things if you have injured your foot. So you have to look at your feet. If you can’t see the bottom of your feet, there are all kinds or mirrors out there that are on long sticks that you can put the mirror down to the ground and put your foot above it. Have a family member look at your foot. So that’s the very first thing.

The next thing I am going to recommend is that when you go to see your primary care doctor, at every visit you take your shoes and socks off. Make them look at your feet. Believe it or not, only 35 percent of patients with diabetes get an annual foot examination, only 35 percent. We are not going to prevent any of these problems if we are not even looking at our feet. So you can help by getting your shoes off, getting your socks off, and making your doctor take a look at them. If there is a problem, they are going to refer you.

I would also recommend that all patients with diabetes get a comprehensive foot evaluation every year, and by comprehensive I mean more than just looking at it. The pulse needs to be looked at so we look at the circulation. We need to measure how much the patient feels so that we know and can quantify what their risk is. Looking for problems in the toenails, this is an instance where if you have fungus in the toenails and they are thick, that can be a serious problem. You can develop an abscess underneath a nail, and you wouldn’t know that it’s there if it doesn’t hurt because you have neuropathy.

You need to be evaluated structurally. Do you have bunions and hammertoes that could be sources of problems? Again, you develop a corn, you don’t feel things, the shoe keeps rubbing, you don’t remove the shoe, you don’t even say it hurts because you’ve got neuropathy. You’ve got to see somebody about that so that that’s looked at. And then mechanically, the way that somebody walks needs to be looked at to see if that’s going to be a problem. And only then can the appropriate long-term strategy be devised for an individual patient.

And it may be as simple as going in once a year and getting that evaluation. It may mean that your podiatrist wants to see you much more frequently because you are much more at risk. You have bad circulation already, you have really bad neuropathy, you don’t feel things. You are at much higher risk than somebody who has diabetes who has none of those things.

Judy:
Does soaking your feet, to get back to the circulation thing, does soaking your feet in hot water increase the circulation and help you avoid some of these infections?

Dr. Taubman:
Well, in a normal patient if they are exposed to temperature like heat, it will increase the blood flow temporarily for about 15 to 20 minutes. After that your body is going to think you are making a mistake, and it’s going to actually shut the circulation down. Somebody with diabetes should never soak their feet in hot water because you can burn your feet. I see patients every year who have stepped into bath water that they are drawing up. It’s too hot, and they don’t feel things. They step in it, and they develop second degree burns on their feet because the temperature is too hot, and it doesn’t hurt. Think about how we test water. You should be testing water by using a body part that doesn’t touch the ground or touch things like your fingertips, such as your elbow or another more sensitive part. I don’t know if you have children, but when you had, if you are a female and you had children and you were feeding them with a bottle, and you heated that bottle, what did you do?

Judy:
You put it on your wrist.

Dr. Taubman:
You put the milk on your wrist. Why do you do that? Because it’s much more sensitive to temperature. You didn’t put it in the palm of your hand. The same applies in testing water if you have diabetes. The water should not be hot, should not be hotter than what you can tolerate by putting your elbow or the top of your hand into it, not the palm.

Judy:
So how does obesity play into the whole diabetes problem and, in particular, the diabetic foot problems?

Dr. Taubman:
Well, let’s talk a little bit about the two kinds of diabetes that we have in this country. We have type I diabetes and type II. Type I is the typical, what we used to call juvenile diabetes. Children would get diabetes associated with the fact that their pancreas, an organ in their belly, stopped making insulin. That accounts for only 5 percent of the diabetes in the United States.

The vast majority of people in the United States develop diabetes because they become overweight. And what happens is when you become fat, your body fat cells interfere with the absorption of insulin, and so what happens is your body keeps putting more insulin out. Insulin is a chemical that’s made by the pancreas that’s designed to pull the sugar out of your bloodstream. So your body keeps pouring more insulin out, and eventually your pancreas will stop making insulin in type II diabetes. But it’s obesity that’s the primary reason why we have that. We have an epidemic of obesity in the United States. It’s not hard to understand why we have an epidemic of diabetes associated with it.

So what happens then is because of inactivity, that’s how most of us get diabetes. We eat poorly. We don’t exercise. And sometimes also heredity, we are predisposed to developing diabetes. Those factors are what will determine for most of us why we have an epidemic of type II or obesity or adult onset, what we used to call adult onset diabetes. That is a prescription for disaster. Keep in mind too that diabetes, when you are getting complications associated with the feet, you are not getting that in a vacuum. Diabetes affects your eyes, the back part of your eye called the retina. It affects your heart. It affects your kidneys. It affects the gums in your mouth. So really your whole body is affected by just too much, too high of a level of blood sugar, and the foot is just another area that gets it.

Judy:
Well, we were talking a little bit before the show started about the unusually high rates of diabetes and obesity among African-Americans who I gather have twice the rate of those twin epidemics, and the same for Native Americans who have four times the rate. What about foot problems in these groups, are they also extra high?

Dr. Taubman:
Well, the complication rate associated follows what you just described. Ethnic minorities in the United States have at least twice the rate and Native Americans four times the rate of diabetes as Caucasians in the United States. And consequently, the amputation rate in patients who are of ethnic minority are at least twice that of Caucasians. So, yes, they do have higher rates of complications. It sort of naturally would seem to follow. So if you have twice as many African-Americans than Caucasians that are getting diabetes, it sort of follows that their complication rate would be twice as high. Again, it can be prevented.

And one of the things I haven’t even talked about, which I need to, is smoking. If you smoke, you have six times the rate of needing an amputation than somebody who doesn’t smoke associated with diabetes. If you have diabetes, you shouldn’t be smoking.

Judy:
Is that again because it affects the circulation?

Dr. Taubman:
It does. What smoking does is it interferes with the oxygen exchange at the cellular level in the blood vessels. So what happens is your body knows that it needs to provide more oxygen for the essential organs, your brain, your heart, your lungs. And so it steals that oxygen away from what we call the periphery, from the toes and the fingers. So it really severely affects the circulation in the feet. Nobody should smoke. But if you have diabetes, you have got to quit. It’s just a prescription for disaster, and one that you can single-handedly prevent that amputation by not smoking in the first place.

Judy:
Well, again back to the whole shoe thing that you were talking about earlier, we all have heard over and over that high heels are terrible for the feet. But what about flip-flops and Crocs, the shoes, those funny-colored, kind of big, fat clunky, chunky-looking shoes called Crocs that everybody seems to love, are they got good or bad for the feet? Flip-flops and Crocs?

Dr. Taubman:
They are great for my business, Judy. I can tell you that. So they are keeping me going.

Judy:
The flip-flops or the Crocs?

Dr. Taubman:
They are both keeping me going in some respects, so let’s talk about them so that the listeners understand what you are supposed to be looking for. First of all, in moderation, you can get away with almost anything with regards to footwear. You also should not be using, if you are going out running, you should not be using Crocs or flip-flops to be running in them. You should be using a running shoe that’s designed for that activity.

But one of things that happens in those style shoes, flip-flops especially, is they make you take shorter steps. Your toes have to grip, your legs don’t swing the same way when you are wearing a shoe that your foot is having to grip with. So it’s a type of shoe that was really designed to go to the beach or to go swimming where you need some protection on your foot, but it’s designed to be taken off so that you can get into the water and do other things. Now, if you are going to look for a flip-flop, you should be looking for one that has some contour to the heel, that has some decent arch support. It should be made of natural materials. Materials like rubber and plastic can cause the skin to sweat more, can develop blisters, athlete’s foot, other kinds of infections, so those are things that you need to think about.

Crocs are slightly different. They are generally made of plastic, and so that’s one issue, but they do have holes that are designed to breathe. They do have better arch support than the average shoe. Again, it’s a shoe to sort of to knock around in. It’s not a shoe to spend all day in, to go walking for eight or 10 or 12 hours a day in. That’s not what that shoe is designed for. But they are trendy, and people like them.

Again, if you go on the Web site at www.apma.org, you can see some flip-flops that are made of better materials that have some of the features that we just talked about, and so they are appropriate for the kinds of activities that they are designed for.

Judy:
Dr. Ross Taubman, I have to cut you off there because we are just out of time. Thank you so much, Dr. Taubman, president of the American Podiatric Medical Association. You have been very enlightening. So thank you, and thank you, listeners, for joining us. Until next week, I am Judy Foreman. Good night.

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